Layperson standard for emergency care is under attack

Hundreds of Americans who recently sought treatment in emergency rooms have had insurance claims denied, leaving them owing thousands of dollars in medical bills. Is this the next health care battle in Iowa?

Those with denied claims live in Missouri, Georgia and Kentucky and are insured by Indianapolis-based insurance giant Anthem. In Iowa, the company operates as Amerigroup, which provides Medicaid managed care.

A letter, sent last year, spells out Anthem’s new emergency room policy in bold, blue text: “Save the ER for emergencies — Or you’ll be responsible for the cost.”

Those with denied claims believe the insurance company is making decisions based on medical diagnosis instead of problems that led to emergency care. A 27-year-old Kentucky woman, for instance, sought care for what she believed to be potentially lethal appendicitis. It turned out to be ovarian cysts, and Anthem refused to pay.

A California man gets fluids in an IV as he lies on a bed with the flu in the emergency room at Palomar Medical Center in Escondido, California, U.S., January 18, 2018. (Mike Blake/Reuters)

A Missouri pedestrian, struck by a vehicle, was taken to the emergency room with bad scrapes and bruising. Although the pedestrian was suspected of having broken bones, none were discovered. Anthem denied that claim, too.

Similar stories prompted U.S. Sen. Claire McCaskill, D-MO, to request documentation of how the company is making decisions.

“Patients are not physicians,” McCaskill wrote. “I am concerned that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events.”

The principle of covering care based on symptoms that most people would consider potentially life-threatening, rather than a final diagnosis is the prudent layperson standard. Following years of insurance denials, 47 states codified the standard, which was also adopted federally as part of the Affordable Care Act. While the standard isn’t present in Iowa Code, it is included in agency rules that govern how the Code is implemented.

Inclusion of such language, however, hasn’t stopped Anthem from implementing its questionable policy.

Analysis of the list of nearly 2,000 diagnostic codes used by Anthem to deny emergency care coverage in Missouri found that only 15 percent are medically considered non-emergency situations. Included on this list is influenza, which has proved especially deadly this season.

Anthem responded to the analysis by the Missouri Hospital Association by saying the group used an outdated code list, and by refusing to disclose a current version.

Prudent layperson standards were adopted to protect patients seeking medical care for potentially life-threatening conditions, and also to provide reimbursement assurances to hospitals.

Anthem’s new emergency policy not only creates an incentive for patients to delay or not seek appropriate medical care, it’s already placing a financial strain on hospitals, especially rural facilities.

Anthem’s member handbook for Iowa enrollees does not currently include language related to the new emergency room policy, but the insurance company has announced plans to expand the policy into Indiana, New Hampshire and Ohio this year.

This column by Lynda Waddington originally published in The Gazette on Feb. 3, 2018. Photo credit: Mike Blake/Reuters